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APPLICATION FOR WELL/PUMP PE JOAQUIN COUNTY PUBLIC HEALTH WVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In TrlpBeelo) APPLICATION 19 HEM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE W COMPLIANCE MH SAN "AMIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. n '�� JOB AODRESSroR APN# 74 Lincoln Center clrY Stockton PARCEL BIZVAPHs SNC 4a R, Se Lng ry le-7 111 12-fEiC---— (SDCIISj* 1 e ll OWNER'S NAME c/o Donald T. Bradshaw, Levine-Fricke-RecorADOREes Emeryville, CA 4608-1827 PHoNE# CONTRACTOR AODIRESS LIC# RHONE# 950 Howe Rd. (510)31538- Y SM CONTRACTOR Gregg In-Situ, Inc. ADDnFsa Martinez, CA 94553 uc#CA-656407 PHONE# TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MOMORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑N.. El Ppm, H.P. DEPTH PUMP 6ET_17. FIRST WATER LEVEL 0 (TYPE OF PUMP( ❑ OUR-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ® 601E BORING B ❑DESTRUCTION. INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 7-i nrhac DIA.OF CONDUCTOR CASINO N/A 0 ❑ DOMESTICIFRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINO/STEEL/PVC N/A DIA.OF WELL CASINO N/A 0 ❑ PUBLICIAHUNICIPAL 1:1 DRIVEN DEPTH OF GROUT BEAL Total Depth SPECIFICATION Cement-Bentonite R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY contractor GROUT BRAND NAME N/A E ❑ MONITORING GROUT SEAL PUMPED: ®Ys ❑N. CONCRETEPEDESTALBYORIU11141Yw ❑Ne S APPROX.DEPTH 80 feet LOCKING CHESTER BOX/STOVE PPE N/A 5 PROPOSED CONSTRUCTIONIDIOLUNO METHOD: MUD NOTARY AIR ROTARY AUGER CABLE OTHER Hydraulic Push 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULE$ANO REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1914ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENMTON LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUR CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CEWIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,H SHALL EMPLOY PERSONS SUBJECT TO WORXMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE A CANT MUST CALL H HOURS /INS ADVANCE FOR ALL(( REQUIRED INSPECTIONS AT 1201146640I16. COMPLETE DRAWING AT LOWER AREA PROVIDED. 91o:wa x� Site Proiect Manager D.I. P N `7 PLOT RAN ON.1.%P -)%-I- 't. 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED Z. OUTLINE OF THE PROPERTY,BMW DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE INSPOSAL BYSTEMB. 3. DIMENS,QWV OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED rITTY TT. STRUCTURES,IMLUMM COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. �.. L. 1 X� * u.'" 1 \ _ — > L...�a -4.. YI ^ �� l\U 1 ..� ... . 1 .�. ..._M 1..._I= 1 N, 1 I 11I N IJ � .aM4 e G P V3 .. ggg 15 i t B �� ��.�- ROOTAGE � _ B•^ � 1C�A r—` 2.a a8 B\Rmi'.MV g DEPARTMENT US!ONLY APPllvabn Ae.eplsl Ry I Y l-,� /R.Y-'rT✓ Dala I' 1 % � Pre. G,eu1 knpxRlen By J D.R. Pump M.P.vO.n By_- One De.vmnen In.n..Rbn er D.Re D.mm.I$.: C�o f- StD c�fi�-�. �v1�vx�cl�rv�o�-T t� Qe✓✓nit- '�� 3�_ C'x�lo• !.(� ACCOUNTING ONLY: AID# FAC# PE CODES FEEINFO I AMOMT REMITTED I CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE S 299,0 015(0--To Pub.Health Serv.-Enviro.173(1/97)